DSHS Preventable Adverse Events 2017 Update · DSHS Preventable Adverse Events 2017 Update March 2017 Vickie Gillespie Preventable Adverse Events Clinical Specialist 1. Health Care

DSHS Preventable Adverse Events 2017 Update

March 2017

Vickie Gillespie

Preventable Adverse Events

Clinical Specialist

1

http://www.dshs.state.tx.us/default.shtm


Health Care Safety Group

2

• Healthcare Associated Infections

– Central line-associated bloodstream infections in certain special care settings (ICUs & CCUs, NICUs)

– Catheter associated urinary tract infections in ICUs & CCUs (NICUs excluded)

– Surgical site infections

• Multi-drug Resistant Organism Reporting

• Preventable Adverse Events (PAE)



Objectives

1. Discuss key aspects of the Texas DSHS Preventable Adverse Event (PAE) Reporting Program.

2. Explain the PAE reporting requirements for SSIs.

3. Identify at least 2 available resources.

3



Washington Post Article of May 3

“Medical errors now third leading cause

of death in the United States”

Recent study published in the BMJ analyzed 4 large

studies dating 2000-2008

Estimated 251,000 deaths/year in US—685/day

700 per day or 9.5% of all deaths

3rd leading cause after heart disease and cancerMakary, Martin and Daniel, Micheal; Johns Hopkins University School of Medicine

4

Washington Post Article May 2016



Loretta Macpherson

5

• December 2014

• ER for anxiety and med concerns post recent brain surgery

• Fosphentoin (Cerebyx) ordered

• Rocuronium IV given (Zemuron/Esmuron)

• Respiratory/cardiac arrest

• Anoxic brain injury

• Death



http://news.yahoo.com/hospital-says-medication-error-killed-patient-200501465.html

http://news.yahoo.com/hospital-says-medication-error-killed-patient-200501465.html

Scope of the Problem• Falls—

– 700,000-1,000,000 falls annually1

– Leading cause injury-related death 65 & older– $30 billion by 20202,3

• Pressure Ulcers—– 257,412 Medicare patients 20071

– 60,000 patients die annually from HA PUs– Average charge of $43,1804

• Medication Errors—– 1000/day in hospitalized pts5

– 15/100 admissions—75% preventable6

• HAIs—1 out of every 25 patients9

– 2 Million annually in US7 (200,000 in Texas8) 722,000 in US acute hospitals7

– ~ 90,000 deaths (8-9000 Texas deaths) 75,000 during hospitalizations7

– ~ $5 billion - $ 31.5 billion2 healthcare costs6

Scope of the Problem



Mortality and Morbidity

• 1 in 10 hospitalized patients develops an adverse event (AHRQ 2014)

• 1/3 of Medicare beneficiaries in SNF have an adverse event—half of which are deemed preventable (OIG 2014)

• 1 in 20 perioperative med administrations had med error and/or adverse drug event (Nanji et al. 2015)

• > 700,000 ED visits due to adverse drug event--120,000 need admitted (Budnitz et al. 2014)

• 12 Million patients experience diagnostic error (OP care), ½ which have potential to harm (Singh et al. 2014)

• 42.7 Million adverse events in 421 M hospitalizations/year/world (Jha et al. 2013)

Morbidity and Mortality



• Safety Culture

• Systems Thinking

• Swiss Cheese Model

• Slips versus Mistakes

• Blunt vs Sharp End

• Complexity Theory

• Complex Adaptive Systems

• Transparency

• Adverse Event Reporting

• High Reliability

• Nonpunitive Response to Mistakes vs Accountability

• Psychological Safety

• Human Factors Engineering

• RCA2 / FMEA

• Communication

• Teamwork

• Transitions/Handoffs

• Checklists

• Forcing Functions

Patient Safety Science



Survey Content

• Communication Openness

• Compliance With Procedures

• Feedback and Communication About Incidents

• Handoffs

• Management Support for Resident Safety

• Nonpunitive Response to Mistakes

• Organizational Learning

• Overall Perceptions of Patient Safety

• Staffing

• Supervisor Expectations and Actions Promoting Patient Safety

• Teamwork

• Training and Skills

Survey on Patient Safety Culture

Agency for Healthcare Research and Quality 2016 Hospital Survey on Patient Safety Culture



Survey Results

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Nonpunitive Response to Error

Handoffs and Transitions

Staffing

Teamwork Across Units

Communication Openness

Overal Perceptions of Pt Safety

Frequency of Events Reported

Feedback/Communication re/ error

Management Support of Pt Safety

Organizational Learning

Supr/Mgr Expectations/Actions Promoting…

Teamwork Within Units

Agency for Healthcare Research and Quality 2016 Hospital Survey on Patient Safety Culture



11

March 1, 2017

The Joint Commission issued New Safety

Event Alert on Establishing and Improving Safety

Culture in Health Care

The essential role of leadership in developing a safety culture



12



2017 Top 10 Health Technology Hazards

• Infusion Errors

• Inadequate Cleaning of Complex Reusable Instruments

• Missed Ventilator Alarms

• Undetected Opioid-Induced Respiratory Depression

• Infection Risks with Heater-Cooler Devices

• Software Management Gaps

• Occupational Radiation Hazards in Hybrid ORs

• Automated Dispensing Cabinet Setup and Use Errors

• Surgical Stapler Misuse and Malfunctions

• Device Failures Caused by Cleaning Products and Practices

13Adapted from: Health Devices 2016 November. ©2016 ECRI Institute www.ecri.org/2017hazards



Top 10 Safety Concerns• Health IT configurations and organizational workflow that do not

support each other

• Patient identification errors

• Inadequate management of behavioral health issues in non-behavioral-health settings

• Inadequate cleaning and disinfection of flexible endoscopes

• Inadequate test-result reporting and follow-up

• Inadequate monitoring for respiratory depression in patients prescribed opioids

• Medication errors related to pounds and kilograms

• Unintentionally retained objects despite correct count

• Inadequate antimicrobial stewardship

• Failure to embrace a culture of safety

14ECRI Institute’s Risk Management eSource April 2016



Top Ten Checklist

2017 Adverse

Drug Events

15

http://www.hret-hiin.org/Resources/ade/17/HRETHIIN_ADEtoptenChecklist.pdf



Joint Commission 2016 Types of Sentinel Events

• Voluntarily Reported N=824

• 14.6% Unintended Retention of a Foreign Body

• 12.6% Wrong patient, Site, Procedure

• 10.6% Suicide

• 11.2% Fall

• 8.5% Unassigned at time of report

• 6.5% Delay in Treatment

• 5.7% Other Unanticipated Event

• 5.5% Operative/Post-op Complications

• 4.0% Medication Error

• 3.9% Criminal Event

• 36.1% Other16

Summary Data of Sentinel Events Reviewed by The Joint Commission SE Statistics as of: 1/13/2017



Texas Health and Safety Code

• Senate Bill 203 of the 81st Legislature (2009) amended the Health and Safety Code, Chapter 98.102.a.2,4,5, to require:

17

Healthcare facilities to report certain preventable adverse events to the DSHS,

DSHS to make this data available to the public by facility, by type, and by number.

AND



• PAEs are entered by the reporting facility into the Texas Healthcare Safety Network (TxHSN).

--Manual entry online

--XML Upload per TxHSN webservices

• PAE reporting deadlines, comment period and public posting of data follows the established HAI schedule.

18

How to Report



19



First Tier PAE Reporting January 1, 2015

SURGICAL OR INVASIVE

PROCEDURE EVENTS1. Surgeries or invasive

procedures involving a surgery

on the wrong site, wrong

patient, wrong procedure.

2. Foreign object retained after

surgery.

3. Post-operative death of an ASA

Class 1 Patient.

PATIENT PROTECTION

EVENTS1. Discharge or release of a

patient of any age, who is

unable to make decisions, to

someone other than an

authorized person.

20

First Tier PAE ReportingJanuary 1, 2015




ENVIRONMENTAL EVENTS

1. Any incident in which systems designated for oxygen or other gas to be delivered to a patient contains no gas, wrong gas, or are contaminated by toxic substances.

2. Patient death or severe harm associated with use of physical restraints or bedrails while being cared for in a health care facility.

POTENTIAL CRIMINAL EVENTS

1. Abduction of a patient of any age.

2. Sexual abuse or assault of a patient within or on the grounds of a health care facility.

3. Patient death or severe harm resulting from a physical assault that occurs within or on the grounds of a health care facility.

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1. Patient death or severe harm associated with unsafe administration of blood or blood products.

2. Patient death or severe harm associated with a fall in a health care facility resulting in a fracture, dislocation, intracranial injury, crushing injury, burn or other injury.

3. Patient death or severe harm resulting from the irretrievable loss of an irreplaceable biological specimen.

4. Perinatal death or severe harm (maternal or neonatal) associated with labor or delivery in a low-risk pregnancy while being cared for in a health care facility.

5. Patient death or severe harm resulting from failure to follow up or communicate laboratory, pathology or radiology test results.

22

CARE MANAGEMENT EVENTS




26 Expert Panel Participants--

• 1033 CLABSIs

• 1027 CAUTIs

• 2913 SSIs (selected surgeries)

• 545 PAEs

*General Hospitals, State Owned/Operated Hospitals, ASCs

2015 Texas Healthcare Facilities*



Total number of PAE Deaths 2015

PAEs associated with patient deathNumber reported

PAE

Number Deaths

Percent Deaths

Intraoperative or immediately post-operative/post-procedure death in an ASA Class 1 patient 2 2 100%

Perinatal death or severe harm (maternal or neonate) associated with labor or delivery in low-risk pregnancy

17 11 65%

Patient death or severe harm resulting from failure to follow up or communicate laboratory, pathology, or radiology test results

11 2 18%

Patient death or severe harm associated with a fall in a healthcare facility resulting in other injury 17 3 18%

Patient death or severe harm associated with a fall in a healthcare facility resulting in intracranial injury 43 5 12%

Foreign Object Retained After Surgery or Invasive Procedure

121 1 1%

Patient death or severe harm associated with a fall in a healthcare facility resulting in fracture 202 1 0.5%

24



25

2015 Annual Healthcare Safety Report

http://txhsn.dshs.texas.gov/HCSReports/AnnualReports.aspx



Second Tier PAE Reporting January 1, 2016


PROCEDURE EVENTS

1. Deep Vein Thrombosis (DVT) or

Pulmonary Embolism (PE) after

total knee replacement or after

hip replacement.

2. Iatrogenic Pneumothorax with

venous catheterization.

PATIENT PROTECTION

EVENTS

1. Patient suicide, attempted

suicide or self-harm that

results in severe harm, while

being cared for in a health

care facility.

2. Patient death or severe

harm associated with

patient elopement.

26

Second Tier PAE ReportingJanuary 1, 2016




ENVIRONMENTAL EVENTS1. Patient death or severe harm

associated with an electric

shock while being cared for in

a health care facility.

2. Patient death or severe harm

associated with a burn

incurred from any source

while being cared for in a

health care facility.

POTENTIAL CRIMINAL

EVENTS1. Any instance of care ordered

by or provided by someone

impersonating a physician,

nurse, pharmacist or other

licensed health care provider.

27





CARE MANAGEMENT EVENT

1. Any Stage III, Stage IV or

Unstageable pressure ulcer

acquired after

admission/presentation to a


RADIOLOGICAL EVENT


harm associated with the

introduction of a metallic

object into the MRI area.

28




2016 PAEs Q1 PreliminaryPreliminary 2016 PAEs Type of Event 2016 2015

Stage III, IV or Unstageable Pressure Ulcer Acquired after Admission 541 --

Patient Death or Severe Harm Associated with a Fall Resulting in a Fracture 168 202

Foreign Object Retained After Surgery or Invasive Procedure 116 121

DVT/PE after Total Knee Replacement 79 --

Wrong Site Surgery or Invasive Procedure 67 66

Patient Death or Severe Harm Associated with a Fall Resulting in an Intracranial Injury

47 43

Iatrogenic Pneumothorax with Venous Catheterization 43 --

DVT/PE after Hip Replacement 32 --

Wrong Surgery/Procedure 29 29

Patient Death or Severe Harm Associated with a Fall Resulting in Other Injury 19 17

Patient Death or Severe Harm Resulting from Failure to Follow Up or Communicate Laboratory, Pathology or Radiology Test Results

13 11

Perinatal Death or Severe Harm (maternal or neonate) Associated with Labor or Delivery in a Low-Risk Pregnancy

13 17

Patient Suicide, Attempted Suicide, or Self-harm that Results in Severe Harm 10 --

Surgery or Invasive Procedure on Wrong Patient 8 7



Preliminary 2016 Q1 PAEs Type of Event 2016 2015

Patient Death or Severe Harm Associated with a Burn Incurred from Any Source 7 --

Any Incident in which Systems for O2 or Other Gas Contains No Gas, Wrong Gas, or are Contaminated by Toxic Substances

4 8

Patient Death or Severe Harm Associated with Patient Elopement 4 --

Patient Death or Severe Harm Resulting from the Irretrievable Loss of an Irreplaceable Biological Specimen

3 1

Patient Death or Severe Harm Associated with Use of Physical Restraints or Bedrails 3 2

Sexual Abuse or Assault 3 8

Patient Death or Severe Harm Resulting from a Physical Assault that Occurs within or on the Grounds of a Health Care Facility

2 3

Intra-operative or Immediately Post-operative Death of an ASA Class 1 Patient 2 2

Patient Death or Severe Harm Associated with a Fall Resulting in a Dislocation 2 6

Any Instance of Care Ordered or Provided by Someone Impersonating a Physician, Nurse, Pharmacist, or Other Licensed Health Care Provider

1 --

Discharge/Release of Patient of Any Age Who is Unable to Make Decisions, to Someone Other than an Authorized Person

1 1

Patient Death or Severe Harm Associated with Unsafe Administration of Blood or Blood Products

0 1

TOTAL 1217 545



Third Tier PAE Reporting January 1, 2017

PRODUCT OR DEVICE

EVENTS


associated with the use of

contaminated drugs/devices

or biologics provided by the


PRODUCT OR DEVICE

EVENTS


associated with the use or

function of a device in patient

care, in which the device is

used or functions other than

as intended.

31

Third Tier PAE ReportingJanuary 1, 2017





1. Artificial insemination with

the wrong donor sperm or

wrong egg.


harm associated with a

medication error.


Poor glycemic control:

1. hypoglycemic coma

2. diabetic ketoacidosis

3. nonketotic hyperosmolar

coma

4. secondary diabetes with

ketoacidosis

5. secondary diabetes with

hyperosmolarity.

32






PROCEDURE EVENTS

1. Surgical site infections

following spinal, shoulder,

elbow procedure; laparoscopic

gastric bypass,

gastroenterostomy,

laparoscopic gastric restrictive

surgery or cardiac implantable

electronic device.


PROCEDURE EVENTS


harm associated with an

intravascular air embolism

that occurs while being

cared for in a health care

facility

33




Chapter 98 Requirements

Facilities shall report:

An event included in the list of adverse events identified by the National Quality Forum (SREs)

and

A health care-associated adverse condition or event for which the Medicare program will not provide additional

payment to the facility under a policy adopted by the federal Centers for Medicare and Medicaid Services

(HACs).

34

Chapter 98 Requirements



PAEs Reportable in Texas--SREs

• Serious Reportable Event (SRE) “Never Event”

– List of 29 events developed by the National Quality Forum (2002)

– https://www.qualityforum.org/Topics/SREs/List_of_SREs.aspx

• Most begin with “Death or Severe Harm”.

• Some SREs are also HACs.

• There is not a list of associated ICD-10 codes for the SREs.

35

PAEs Reportable in Texas--SREs



PAEs Reportable in Texas--HACs

• Hospital Acquired Conditions (HAC)

– List of 14 Events/Event categories for which Medicare will not provide additional payment to the facility (2006)

– https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/icd10_hacs.html

• Condition not present on admission but is present on discharge

• PAE events that are only HACs are to be reported if they would meet HAC ICD-10 Coding.

36

PAEs Reportable in Texas--HACs



Pressure Ulcers—SRE and HAC

• HAC codes—include Stage III and IV

• SRE—includes Unstageable

• There are no ICD-10 codes for Unstageable(considered Stage III or IV)

• Unstageable Ulcers are to be reported as a PAE—

– “Stage III or Stage IV or Unstageable pressure ulcer acquired after admission/presentation to a health care facility.

Pressure Ulcers—SRE and HAC



Pressure Ulcer Reporting Guidance

On Admission and

DocumentedProgresses to Reportable?

Skin intactStage 3, 4 or

UnstageableYes

Stage 1 Stage 3 Yes

Stage 1 Stage 4 Yes

Stage 1 Unstageable Yes

Stage 2 Stage 3 No

Stage 2 Unstageable Yes

Stage 2 Stage 4 Yes

Stage 3 Stage 4 Yes

Pressure Ulcers Reporting Guidance



HACs Currently Reported to NHSN for Texas Reporting

• CAUTIs in ICUs

• CLABSIs in ICUs/NICUs (VCAIs)

• SSIs following CABG

• SSIs following CIED in Children’s hospitals

• SSIs following spinal fusion in Children’s hospitals

39

HACS Currently Reported to NHSN for Texas Reporting



HACs Reported to TxHSN as PAEs

• Events that are only HACs are to be reported if they meet or would meet the HAC ICD-10 Codes--

DVT/PE after hip/knee surgery (2016)

Iatrogenic Pneumothorax with Venous Catheterization (2016)

Poor Glycemic Control (2017)

SSIs for certain events (2017)

HACS Currently Reported to TxHSN as PAEs



HAC SSIs for PAE Reporting in TxHSN (2017)

• Certain spinal, shoulder, elbow procedures

• Laparoscopic gastric bypass

• Gastroenterostomy

• Laparoscopic gastric restrictive surgery

• Cardiac Implantable Electronic Device (exception Childrens Hospitals)

• https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/icd10_hacs.html

41

HAC SSIs for PAE Reporting 2017



ICD-10 Codes for 755 Surgical Orthopedic HACs

0RQJXZZ Repair Right Shoulder Joint, External Approach

0RQK0ZZ Repair Left Shoulder Joint, Open Approach

0RGJ04Z Fusion of Right Shoulder Joint with Int Fix, Open Approach

0RGJ07Z Fusion of Right Shoulder Joint with Autol Sub, Open Approach

0RGJ0JZ Fusion of Right Shoulder Joint with Synth Sub, Open Approach

0RGJ0KZ Fusion of R Shoulder Jt with Nonaut Sub, Open Approach

0RGJ0ZZ Fusion of Right Shoulder Joint, Open Approach

0RGJ34Z Fusion of Right Shoulder Joint with Int Fix, Perc Approach

0RGJ37Z Fusion of Right Shoulder Joint with Autol Sub, Perc Approach

AND

K6811 Postprocedural retroperitoneal abscess

T814XXA Infection following a procedure, initial encounter

T8460XA Infect/inflm reaction due to int fix of unsp site, init

T84610A Infect/inflm reaction due to int fix of right humerus, init

T84611A Infect/inflm reaction due to int fix of left humerus, init

ICD-10 Codes for Surgical Orthopedic HACs



Intravascular Air Embolism (Death or Severe Harm)

• Excludes death or severe harm associated with certain high risk neurosurgical procedures (head heart)

• Includes but not limited to:• Head and neck procedures

• Vaginal and C-section deliveries

• Spinal instrumentation procedures

• Liver transplants

• Low risk procedures e.g. line placement or IVs

43




Use or Function of Device (Death or Severe Harm)

• Report defects, failures, incorrect use

• Report irregardless if the use is intended or described by the manufacturer.

• Includes implant, medical equipment, medical/surgical supply, HIT device

44

Use or Function of Device(Death or Severe Harm)



Use or Function of Device continued

(Death or Severe Harm)

• Includes, but not limited to, catheters, drains, and other specialized tubes, infusion pumps, ventilators, and procedural and monitoring equipment.

45





• Excludes death or severe harm associated with certain high risk neurosurgical procedures (head above heart)

• Includes but not limited to:• Head and neck procedures

• Vaginal and C-section deliveries

• Spinal instrumentation procedures

• Liver transplants

• Low risk procedures e.g. line placement or IVs

46




Contaminated drugs/devices or biologics (Death or Severe Harm)

• Report irregardless of the source of contamination or product

• Contaminants –physical, chemical, biological

• Report events involving medications, biological products, vaccines, nutritional products, expressed human breast milk, medical gases or contrast media.

47

Contaminated drugs/devicesor biologics (Death or Severe Harm)



Contaminated drugs/devices cont’

or biologics (Death or Severe Harm)

• Includes:

• threat of disease that changes patient’s risk status for life

• contaminations both seen and unseen

• serious infection from contaminated drug/device

• occurrences r/t improperly cleaned / maintained device.

48

Contaminated drugs/devicesor biologics (Death or Severe Harm)



Other Tier 3 PAEs

Artificial insemination with the wrong donor sperm or wrong egg.

• Must report the event when you are made aware of it.

49

Artificial Insemination Errors



Medication Errors (Death or Severe Harm)

• Includes but is not limited to:• Over or under dosing

• Administration of med if known allergy or contraindication

• Drug-drug interaction if known potential for death or severe harm

• Failure to administer prescribed drugs

• Improper use of single or multi-dose vials if leads to dose adjustment problem

• Wrong administration technic50




Medication Errors continued

(Death or Severe Harm)

Excludes:

– reasonable difference in clinical judgment on drug selection/dose

– events associated with allergies that could not have been known or discerned in advance.

51




Poor Glycemic Control

See ICD-10 codes for these:

• Hypoglycemic coma

• Diabetic ketoacidosis

• Nonketonic hyperosmolar coma

• Secondary diabetes with ketoacidosis

• Secondary diabetes with hyperosmolarity

52

Poor Glycemic Control



Glycemic Control Crosswalk

53

HAC 09 - Manifestations of Poor Glycemic Control CROSSWALK

Code Long Description TxHSN PAE POOR GLYCEMIC CATEGORIES

E0800 Diabetes mellitus due to underlying condition with hyperosmolarity without

nonketotic hyperglycemic-hyperosmolar coma (NKHHC)

Poor Glycemic Control – Secondary diabetes with

hyperosmolarity

E0801* Diabetes mellitus due to underlying condition with hyperosmolarity with coma Poor Glycemic Control – Nonketotic Hyperosmolar

coma


hyperosmolarity

E0810 Diabetes mellitus due to underlying condition with ketoacidosis without coma Poor Glycemic Control – Secondary diabetes with

ketoacidosis

E0900 Drug or chemical induced diabetes mellitus with hyperosmolarity without

nonketotic hyperglycemic-hyperosmolar coma (NKHHC)


hyperosmolarity

E0901* Drug or chemical induced diabetes mellitus with hyperosmolarity with coma Poor Glycemic Control – Nonketotic Hyperosmolar

coma


hyperosmolarity

E0910 Drug or chemical induced diabetes mellitus with ketoacidosis without coma Poor Glycemic Control – Secondary diabetes with

ketoacidosis

E1010 Type 1 diabetes mellitus with ketoacidosis without coma Poor Glycemic Control – Diabetic ketoacidosis

E1100 Type 2 diabetes mellitus with hyperosmolarity without nonketotic

hyperglycemic-hyperosmolar coma (NKHHC)

Poor Glycemic Control - Diabetic Ketoacidosis

E1101 Type 2 diabetes mellitus with hyperosmolarity with coma Poor Glycemic Control – Nonketotic Hyperosmolar

coma

E1300 Other specified diabetes mellitus with hyperosmolarity without nonketotic

hyperglycemic-hyperosmolar coma (NKHHC)


hyperosmolarity

E1301* Other specified diabetes mellitus with hyperosmolarity with coma Poor Glycemic Control – Nonketotic Hyperosmolar

coma


hyperosmolarity

E1310 Other specified diabetes mellitus with ketoacidosis without coma Poor Glycemic Control – Secondary diabetes with

ketoacidosis

E15 Nondiabetic hypoglycemic coma Poor Glycemic Control – Hypoglycemic coma

Poor Glycemic Control Crosswalk



• 21% decline in HACS since 2010

• 3 M fewer adverse events

• 125,000 lives saved

• $28 Billion in savings

AHRQ National Scorecard on Rates of Hospital-Acquired Conditions, 2010 to 2015

AHRQ HAC improvements



Texas

ranks

17th

with

78 of 212

(36.9%) scoring

“A”55

Fall 2016 LeapfrogHospital Safety Scores

http://www.hospitalsafetygrade.org/your-hospitals-safety-grade/state-rankings



Health Care Safety

56

http://www.dshs.state.tx.us/idcu/health/Health-Care-Safety/

Health Care Safety Website



http://www.dshs.state.tx.us/idcu/health/Health-Care-Safety/

PAE Resources Updated

57

PAE Website www.paetexas.org



Data Website http://txhsn.dshs.texas.gov/HCSreports

58

Data Website http://txhsn.dshs.texas.gov/HCSreports



http://txhsn.dshs.texas.gov/HCSreports

What is Posted for the Public?

• The PAE results will be included in the HAI public report.

• PAEs will be reported by facility, by name and by number.

• Example:

59

Type of EventTotal

Number

Patient death or severe harm associated with unsafe administration of blood or blood products 1

Surgical site infection following a spinal procedure

1

What is Posted for the Public?



*Help Desk Email*

[email protected]

[email protected]

512-776-7676

Fax 512-776-7616

Contact Information

60

Emily Engelhardt, TxHSN Administrator

Nesreen Gusbi, TxHSN Administrator

Vickie Gillespie, PAE Clinical Specialist

THE HELP

DESK EMAIL

is the FIRST

and BEST

PLACE TO

CONTACT FOR

QUESTIONS

or

ASSISTANCE.

Contact Information



TxHSN Reporting Schedule

61

Reporting Quarter Q1: Jan 1

– Mar 31

H1: Jan 1

– June 30

Q3: July 1

– Sept 30

H2: July 1

– Dec 31

Facility data submission deadline Within 60 days of end of reporting quarter

DSHS takes preliminary data snapshot 1-Jun 1-Sept 1-Dec 1-Mar

DSHS sends email to facility users

review data~15-Jun ~15-Sep ~15-Dec ~15-Mar

Facility data corrections due Last day to verify no PAEs to report for half year

30-Jun 30-Sep 31-Dec 31-Mar

DSHS takes final data snapshot 1-July 1-Oct 1-Jan 1-Apr

DSHS sends email to facility to review

data summary and make commentsNA 15-Oct NA 15-Apr

Facility comment period deadline NA 30-Oct NA 30-Apr

DSHS reviews comments NA 15-Nov NA 15-May

Public posting of data summary with

approved commentsNA 1-Dec NA 1-Jun



*Help Desk Email*

[email protected]

[email protected]

512-776-7676

Fax 512-776-7616

Contact Information

62

Emily Engelhardt, TxHSN Administrator

Nesreen Gusbi, TxHSN Administrator

Vickie Gillespie, PAE Clinical Specialist

THE HELP

DESK EMAIL

is the FIRST

and BEST

PLACE TO

CONTACT FOR

QUESTIONS

or

ASSISTANCE.

Contact Information



Questions?

Thank you!

Questions?



64



Documents

DSHS Preventable Adverse Events 2017 Update · DSHS Preventable Adverse Events 2017 Update March 2017 Vickie Gillespie Preventable Adverse Events Clinical Specialist 1. Health Care